If you are interested in a new patient appointment, please fill out this form as completely as possible. If you can't provide the requested information type "unknown" or "declined" but be aware that this may delay your ability to make an appointment.
Fill out each section of the form and click NEXT to move to the next section of the form.

The Patient's Address:
Street Address:
Address Line 2:
City:
State:
Zip code:
The following information is for the primary insurance subscriber if different from the patient: (if same check this box
)
Subscriber's Name:
Subscriber's Birth Date:
Subscriber's SSN:
Subscriber's Address, City, State & Zip:
Address:

City:
State:
Zip:

The following information is for the secondary insurance subscriber:
If same as the patient check this box:
(only one of these boxes can be checked at a time)
If same as the first subscriber check this box:
(only one of these boxes can be checked at a time)
2nd Subscriber's Name:
2nd Subscriber's Birth Date:
2nd Subscriber's SSN:
2nd Subscriber's Address, City, State & Zip:
Address:

City:
State:
Zip:

Who referred you to our office?
Who is your Primary Care Provider?
Who is your therapist? (if you have one)
Who should be contacted in the event of an emergency?
Provide an Emergency Contact Phone Number:

Please complete the Demographics section before clicking NEXT.

Are you being discharged from a hospital and need an urgent appointment? Yes:
No:

We will need a copy of the record from that hospitalization or evaluation for your appointment.

Please answer the discharge question before clicking NEXT.

Please answer the following questions to see if you would benefit from our Advanced Depression Treatment program.
1. Were you being treated for depression or suicidal thoughts/behaviors?
Yes:
No:
2. Have you been treated with 4 or more antidepressant medications?
Yes:
No:
3. Have you tried counseling/therapy?
Yes:
No:
3a. If no, did you participate in counseling while inpatient?
Yes:
No:
4. Have you been diagnosed with a psychotic disorder (ever) or substance abuse (within the last 6 months)?
Yes:
No:
5. Do you have a medical provider who prescribes your psychiatric medication?
Yes:
No:
5a. If yes, are you looking for a new provider or are you in need of an urgent appointment but plan on following up with your regular provider?
Yes:
No:

Advanced Depression Treatment program candidates will get a priority appointment.

Please select at least one reason before clicking NEXT.

Please answer the following questions to see if you would benefit from our Advanced Depression Treatment program.
1. Does your depression cause significant impairment or distress in at least one area of life
(work, school, marriage, social, family, etc.)?
Yes:
No:
2. Have you been dissatisfied with the results of antidepressant medication treatment?
Yes:
No:
3. Have you tried counseling/therapy?
Yes:
No:
3a. If no, are you interested in non-medication options for depression other than therapy?
Yes:
No:
4. Have you been diagnosed with a psychotic disorder (ever) or substance abuse (within the last 6 months)?
Yes:
No:
4a. If no, are you interested in non-medication options for depression other than therapy?
Yes:
No: